Grief is a Mental Illness…Really?

A controversial decision to reclassify grief as a mental illness has been criticised by medical experts.

The change in classification was intended to add flexibility to how early people can be treated for depression following the death of a loved one. But it has led to worries that bereaved people will be treated with pills rather than empathy.

An editorial in influential medical journal, The Lancet, argues that grief does not require psychiatrists and that ‘legitimizing’ the treatment of grief with antidepressants ‘is not only dangerously simplistic, but also flawed.’

The unsigned lead editorial reads: ‘Grief is not an illness; it is more usefully thought of as part of being human and a normal response to the death of a loved one.’

The Lancet’s comments follow the American Psychiatric Association’s decision to add grief reactions to their list of mental illnesses in their fifth edition of the psychiatry ‘bible’, Diagnostic and Statistical Manual of Mental Disorders, (DSM-5), which is due out in 2013.

But The Lancet, along with many psychiatrists and psychologists have called for the changes to be halted – saying they would lead to a ‘tick box’ system that did not consider the wider needs of patients but labelled them as ‘mentally ill’.

They agree that in rare cases, bereavement will develop into prolonged grief or major depression that may merit medical treatment. However, they suggested that for the majority of the bereaved, ‘doctors would do better to offer time, compassion, remembrance and empathy, than pills.’

The DSM-5 proposal – which has been opposed by The Lancet’s editorial writers – would eliminate the so-called ‘grief exclusion.’

This ‘exclusion’ means that anyone who has experienced bereavement cannot be diagnosed as depressed for a certain period of time.

In a previous edition, DSM-III, that period of time was set at one year.

The DSM-IV reduced that period to two months and DSM-5 plans to reduce the period to just two weeks.

Although the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would not directly affect clinical practice here, where doctors tend to use different international guidelines, experts say it would eventually influence research and thinking in the field.

Defending the change in timeframe, Dr. Kenneth S. Kendler, a member of the DSM-5 Mood Disorder Working Group, said it would allow for an earlier diagnosis but would by no means force it.

Simon Wessely, of the Institute of Psychiatry, King’s College, London, said ‘We need to be very careful before further broadening the boundaries of illness and disorder.’

‘Back in 1840 the Census of the United States included just one category for mental disorder.

‘By 1917 the American Psychiatric Association recognised 59, rising to 128 in 1959, 227 in 1980, and 347 in the last revision. Do we really need all these labels? Probably not. And there is a real danger that shyness will become social phobia, bookish kids labelled as Asperger’s and so on.’

Whereas people who are bereaved are currently given help where necessary, in future they might find themselves labelled as having a depressive disorder if their symptoms lasted longer than a certain period of time, he added.

Peter Kinderman, Professor of Clinical Psychology and Head of Institute of Psychology, University of Liverpool, said ‘It will exacerbate the problems that result from trying to fit a medical, diagnostic, system to problems that just don’t fit nicely into those boxes.

‘Perhaps most seriously, it will pathologise a wide range of problems which should never be thought of as mental illnesses. Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labelled as ‘mentally ill’.

Dr. Arthur Kleinman, a Harvard psychiatrist, social anthropologist and global health expert, says that the main problem is the lack of ‘conclusive scientific evidence to show what a normal length of bereavement is.’

According to the Lancet writers, ‘it is often not until 6 months, or the first anniversary of the death, that grieving can move into a less intense phase.’

They added that grieving is individual, shaped by age, gender, religious beliefs and the strength of the relationship with the lost loved one.